Vol. 11 •Issue 8 • Page 16
Long-term Vent Program Expands Against Reimbursement Odds
If you ask case managers what their most difficult patient placement issue is, you will most likely be told it’s the long-term ventilator patient. As our population ages and technologies improve, we’re faced with a growing need for post-acute care services for this patient population.
Upon the 1998 restructuring of the Medicare Prospective Payment System, respiratory therapy in post-acute care virtually dried up overnight. Long-term care facilities no longer could afford to care for the high acuity patients who the hospitals desperately needed to move out of the ICUs to alternate care sites for extended care.
Many long-term care companies fell into bankruptcy as a result of the payment cuts. The entire long-term care industry was set back drastically with the stroke of a pen in Washington, D.C. This, in turn, had a dramatic effect on hospitals because they were then faced with the dilemma of trying to place patients with very few facilities to choose from.
In order to understand the industry’s dilemma with caring for long-term ventilator patients, it’s important to understand the maze of reimbursement issues. Long-term care is funded in a variety of ways, which include Medicare skilled nursing benefits for 100 days, Medicaid programs that are managed by the states, some private commercial insurance and private pay for those who can afford it. All in all, the reimbursement stream is poor, and effective management is key.
The Medicare rates are all tied to the patient’s rehabilitation potential. They also vary with location; skilled nursing facilities in metropolitan areas are reimbursed more than their counterparts in rural areas. The theory is that the cost of care is more in the city than in the country. If only we could convince vendors to charge less according to region, then this theory would possibly work.
Under state Medicaid, the reimbursement rates for per-day care generally range from $90 to $200. It’s virtually impossible to adequately care for a ventilator patient at these reimbursement levels. While a few states have adopted a higher payment rate for ventilator-dependent patients, most haven’t. In those states with increased Medicaid funding, it still remains .inadequate if you take into account the extra staffing needs and medical needs of this patient group.
Commercial insurance and managed care programs also have limits on the length of time they will pay for skilled nursing services. At some point, the benefits run out, and patients eventually fall into the Medicaid system.
Because of the low payment rates, very few long-term care facilities are willing to make the capital investment needed to fund a ventilator unit’s startup and shoulder its risks. Many of the existing programs around the country are facing financial hardship, and recently some have opted to close. This is unfortunate when considering the increased demand for post-acute care services.
WORKING WITHOUT A BLUEPRINT
Despite the obvious challenges, the need for ventilator services in the long term care arena was clear. With this in mind, Respiratory Support Services, a division of Professional Medical Associates LLC, Livingston, Tenn., set out in July 2001 to establish a ventilator program that would be both cost and clinically effective. We started from scratch, relying on years of previous experience in health care and its reimbursement intricacies.
The program was created in partnership with The Health Center at Standifer Place in Chattanooga, Tenn. Standifer Place is a 500-plus bed facility with skilled nursing beds, as well as intermediate care, assisted living and independent living areas. The program was structured to be a “shared risk” situation with each party contributing expertise, staff, etc. Our part would be to provide program management, supplies, respiratory therapy staff and capital equipment. The ventilator unit was established on an easily accessible wing of the skilled nursing section of the facility.
The initial idea was to set up an eight-bed unit to care for difficult-to-wean patients, those who needed family teaching prior to home ventilation, or those who already had been weaned but needed continued monitoring prior to going home. After two months it was obvious that the demand would be greater than anticipated, so the unit was expanded to 16 beds; it’s currently expanding to 30 beds.
Because the ventilator unit existed outside the hospital setting, we established criteria to evaluate the medical complexity of the patients. Essentially, our patients must be medically stable. We developed criteria using the American College of Chest Physicians standards published in the 1998 consensus statement on long-term ventilator care.1 Additionally, we had input from our medical director, Suresh Enjeti, MD, a pulmonologist who works hand-in-hand with the RT staff to establish protocols, provide patient care and perform administrative services.
We’re fortunate to have assembled a strong staff of dedicated RTs. Each of them had extensive background in ventilator care from various area hospitals, and we were able to incorporate many successful methodologies and thought patterns into our program. Their level of enthusiasm and dedication is such that many of them are in the facility on their off time to celebrate a patient discharge. A ratio of therapists to patients of 1-8 was established as a maximum; however, we generally maintain a 1-6 ratio.
Although the ventilator unit is outside of the hospital setting, the facility provides state-of-the art modes of ventilation. In times of emergency, a generator provides back-up power, but the ventilator unit will operate on internal battery if the need arises. All patients are monitored with continuous pulse oximetry, and there’s a redundant pressure alarm on all patient systems. Blood gases are done at the bedside, and lab services also are performed in the unit.
So far, we have admitted more than 60 patients to the unit. Approximately 50 percent were difficult-to-wean ventilator cases. To date, our outcomes indicate a 75 percent to 80 percent successful wean rate with a 65-day average wean time. Much of this success is attributed to our low patient to therapist ratio, which allows our therapists to stay with the patient to coach them through anxious times during the weaning process. There’s a positive “don’t give up” attitude.
As a result of the positive outcomes, we have ongoing conversations with managed care case managers about the effectiveness of the program and how it can be expanded to include other patients with varying disease progression. Because the unit is one of very few resources available, it receives patients from a multistate region. It’s not uncommon to receive referrals from as far away as Ohio or Florida.
The program is still very young and is in a constant state of expansion and improvement. It’s certainly not one of those ideas that excites the investor types. It remains a somewhat risky endeavor, which, if not tightly managed, will quickly become a financial nightmare.
Unfortunately the issue of poor reimbursement has no quick fix. This will remain a problem in the system for years to come as this patient group comprises a small part of the overall mounting health care needs and expenditures in the United States. Keeping our program cost effective is a daily challenge in light of our staffing patterns and our patient’s needs.
The unit was created to satisfy a growing need, and from that perspective it’s a tremendous success.
FINDING VENT FACILITIES
Because of the lack of resources for long-term ventilator patients, we’re attempting to identify as many ventilator facilities as possible. We intend to provide a Web-based resource, http:www.ventweaning.com, which will identify long-term acute care hospitals, skilled nursing facilities who accept ventilator patients, home care companies, and other community resources for patients and families. Along with the listings will be a narrative of the services offered by each facility.
1. Mechanical Ventilation Beyond the Intensive Care Unit. ACCP Consensus Statement. Chest. 1998 May;113(5):Supplement.
Gantt is president of Professional Medical Associates LLC, Livingston, Tenn., Respiratory Support Services (RSS) division. He can be reached at (931) 823-3702, or e-mail [email protected].